Comparison of atherosclerotic risk factors in Asian Indian and American Caucasian patients with angiographic coronary artery disease

Prevalence of Cardiovascular Risk Factors and Coronary Angiographic Findings in High-Risk Immigrant Communities in Italy

BACKGROUND

The prevalence of coronary artery disease (CAD) considerably varies by ethnicity. High-risk populations include patients from Eastern Europe (EEP), the Middle East and North Africa (MENAP) and South Asia (SAP).

METHODS

This retrospective study aims to highlight cardiovascular risk factors and specific coronary findings in high-risk immigrant groups. We examined the medical records and coronary angiographies of 220 patients from the above-mentioned high-risk ethnic groups referred for Acute Coronary Syndrome (ACS) and compared them with 90 Italian patients (IP) from 2016 to 2021. In the context of high-risk immigrant populations, this retrospective study aims to shed light on cardiovascular risk factors and particular coronary findings. We analyzed the medical records of 220 patients from the high-risk ethnic groups described above referred for ACS and compared them with 90 IPs between 2016 and 2021. In addition, we assessed coronary angiographies with a focus on the culprit lesion, mainly evaluating multi-vessel and left main disease.

RESULTS

The mean age at the first event was 65.4 ± 10.2 years for IP, 49.8 ± 8.5 years for SAP (Relative Reduction (ReR) 30.7%), 51.9 ± 10.2 years for EEP (ReR 26%) and 56.7 ± 11.4 years for MENAP (ReR 15.3%); p < 0.0001. The IP group had a significantly higher prevalence of hypertension. EEP and MENAP had a lower prevalence of diabetes. EEP and MENAP had a higher prevalence of STEMI events; SAP showed a significant prevalence of left main artery disease (p = 0.026) and left anterior descending artery disease (p = 0.033) compared with other groups. In SAP, we detected a higher prevalence of three-vessel coronary artery disease in the age group 40-50.

CONCLUSIONS

Our data suggest the existence of a potential coronary phenotype in several ethnicities, especially SAP, and understate the frequency of CV risk factors in other high-risk groups, supporting the role of a genetic influence in these communities.

Inter-ethnic differences in normal coronary anatomy between Caucasian (Polish) and Asian (Korean) populations

PURPOSE

Little is known about ethnic differences in the size of coronary arteries in disease-free individuals. Our aim was to compare coronary artery dimensions between Asian and Caucasian population without atherosclerosis.

METHODS

One hundred and twelve Caucasian patients without any discernible atherosclerosis detected on coronary computed tomography angiography were matched with 112 Asian patients using sex, age, coronary dominance pattern and body surface area (BSA). Maximal and minimal lumen areas (LA) and diameters (LD) of proximal and middle coronary segments were measured, and the mean values were used for analyses.

RESULTS

Caucasians had larger LA and LD than Asian patients in all proximal coronary segments. Overall, the mean difference in LA and LD was 11.4 % and 5.2 %, respectively. Significant differences were observed for all proximal segments (left anterior descending: 13 % and 6%, left circumflex 14 % and 8% and right coronary artery 8% and 4% for LA and LD), but not for mid segments. The greatest difference between Caucasians and Asians was found in left main coronary artery (LMCA) LA (21.2 ± 6.5 vs.16.8 ± 5.4 mm², p < 0.01 respectively). The independent predictors of larger LA and LD of LMCA and proximal coronary segments were male sex (p < 0.05), Caucasian ethnicity (p < 0.05), and left dominance pattern (p < 0.05).

CONCLUSION

In subjects without atherosclerosis, Asians have smaller dimensions of all proximal coronary arteries, most prominently displayed in LMCA, than the Caucasians regardless of age, sex, or body size.

Comparison of the Diameters of the Major Epicardial Coronary Arteries by Angiogram in Asian-Indians Versus European Americans <40 Years of Age Undergoing Percutaneous Coronary Artery Intervention

Coronary artery disease (CAD) rates are higher in Asian-Indians than in Caucasians. CAD occurs at an earlier age in this group, with about a quarter of all myocardial infarctions occurring under the age of 40. Previous reports have suggested smaller coronary artery size in Asian-Indians as a major cause for increased CAD in this population. This study sought to evaluate the size of normal "atheroma-free" segments of the epicardial coronary arteries in Asian-Indians and Caucasians aged ≤40 years undergoing coronary artery intervention in other diseased segments. A total of 69 consecutive patients (41 whites, 28 Asian-Indians) aged ≤40 years were evaluated. Angiograms were analyzed using standard quality control analysis software with digital acquisition. The arteries measured were the left main, left anterior descending, left circumflex, and the right coronary artery. Conventional risk factors, including hypertension, smoking, and diabetes, that could influence coronary size were also assessed. The coronary arteries of Asian-Indian patients showed significantly smaller values in the mean diameters of the left main (2.96 mm vs 4.04 mm, p = 0.0004), left anterior descending (2.48 mm vs 3.24 mm, p = 0.0005), left circumflex (2.52 mm vs 3.06 mm, p = 0.00002), and right coronary artery (2.71 mm vs 3.65 mm, p = 0.0008) as compared with Caucasians. Even after correction for body surface area, a statistically significant difference remained in coronary artery diameters. In conclusion, statistically significant difference in the mean diameter size even after correction for body surface area in Asian-Indians has implications for predisposition to atherosclerosis, and more challenging performance of procedures such as coronary artery bypass grafting, stent implantation, or atherectomy.

An Evaluation of the Numbers and Locations of Coronary Artery Disease with Some of the Major Atherosclerotic Risk Factors in Patients with Coronary Artery Disease

INTRODUCTION

Despite definite recognition of major atherosclerotic risk factors, the relationship between the pattern of coronary artery disease and these risk factors is unknown.

AIM

The aim of this study was to identify the relationship between some of the major atherosclerotic risk factors and the number and pattern of coronary artery disease in patients with coronary artery disease who presented to Farshchian Heart University Hospital, Hamadan, Iran.

MATERIALS AND METHODS

In this descriptive cross-sectional study, we investigated some of the major atherosclerotic risk factors and their relationships with the type of coronary artery disease in terms of number and location of disease. A total of 1100 patients were enrolled with coronary artery disease confirmed by selective coronary angiography from 2010-2014. A p-value<0.05 was considered statistically significant.

RESULTS

A total of 1100 patients enrolled in this study. The patient population consisted of 743 (67.5%) males and 357 (32.5%) females. A meaningful relationship existed between ageing, diabetes mellitus, hypertension and 3-Vessel Disease (3VD, p<0.001) as well as between hyperlipidemia and Single Vessel Disease (SVD, p<0.001). Patients diagnosed with diabetes mellitus, hypertension, and hyperlipidemia showed greater potential to develop coronary artery disease at the proximal section of the coronary arteries.

CONCLUSION

Based on the relationship between some of the major risk factors and the pattern of coronary artery disease in the current study, prospective studies should investigate other risk factors. We recommend that a plan should be developed to reduce adjustable risk factors such as diabetes mellitus, hypertension and hyperlipidemia in order to decrease coronary artery disease.

Inter-Ethnic Differences in Quantified Coronary Artery Disease Severity and All-Cause Mortality among Dutch and Singaporean Percutaneous Coronary Intervention Patients

BACKGROUND

Coronary artery disease (CAD) is a global problem with increasing incidence in Asia. Prior studies reported inter-ethnic differences in the prevalence of CAD rather than the severity of CAD. The angiographic "synergy between percutaneous coronary intervention (PCI) with taxus and cardiac surgery" (SYNTAX) score quantifies CAD severity and predicts outcomes. We studied CAD severity and all-cause mortality in four globally populous ethnic groups: Caucasians, Chinese, Indians and Malays.

METHODS

We quantified SYNTAX scores of 1,000 multi-ethnic patients undergoing PCI in two tertiary hospitals in the Netherlands (Caucasians) and Singapore (Chinese, Indians and Malays). Within each ethnicity we studied 150 patients with stable CAD and 100 with ST-elevated myocardial infarction (STEMI). We made inter-ethnic comparisons of SYNTAX scores and all-cause mortality.

RESULTS

Despite having a younger age (mean age Indians: 56.8 and Malays: 57.7 vs. Caucasians: 63.7 years), multivariable adjusted SYNTAX scores were significantly higher in Indians and Malays than Caucasians with stable CAD: 13.4 [11.9-14.9] and 13.4 [12.0-14.8] vs. 9.4 [8.1-10.8], p<0.001. Among STEMI patients, SYNTAX scores were highest in Chinese and Malays: 17.7 [15.9-19.5] and 18.8 [17.1-20.6] vs. 15.5 [13.5-17.4] and 12.7 [10.9-14.6] in Indians and Caucasians, p<0.001. Over a median follow-up of 709 days, 67 deaths (stable CAD: 37, STEMI: 30) occurred. Among STEMI patients, the SYNTAX score independently predicted all-cause mortality: HR 2.5 [1.7-3.8], p<0.001 for every 10-point increase. All-cause mortality was higher in Indian and Malay STEMI patients than Caucasians, independent of SYNTAX score (adjusted HR 7.2 [1.5-34.7], p=0.01 and 5.8 [1.2-27.2], p=0.02).

CONCLUSION

Among stable CAD and STEMI patients requiring PCI, CAD is more severe in Indians and Malays than in Caucasians, despite having a younger age. Moreover, Indian and Malay STEMI patients had a greater adjusted risk of all-cause mortality than Caucasians, independent of SYNTAX score.

Prevalence of coronary artery calcium scores and silent myocardial ischaemia was similar in Indian Asians and European whites in a cross-sectional study of asymptomatic subjects from a U.K. population (LOLIPOP-IPC)

BACKGROUND

Coronary heart disease (CHD) mortality is 70% higher among Indian Asians (IA) than European whites (EW), the reasons for this excess remain unexplained. Coronary artery calcification (CAC) is highly correlated with coronary plaque burden and silent myocardial ischaemia in EW; but fails to identify excess risk in IA. We hypothesised that IA have a higher prevalence of silent myocardial ischaemia compared to EW, despite similar CAC, and this may explain their excess CHD mortality.

METHODS

CAC was measured for 2,369 asymptomatic men and women, aged 35 to 75 years, as part of the London Life Sciences Population (LOLIPOP) study. 518 subjects had CAC scores >100 Agatston units and of these 256 (49%) patients underwent myocardial perfusion scintigraphy (MPS).

RESULTS

CAC scores were similar among IA and EW, after adjustment for conventional risk factors. MPS abnormalities were seen in 56 (22%) subjects. Presence of diabetes (P = .03) and increasing CAC (P < .001) were independent predictors for severity of silent myocardial ischaemia. Ethnicity did not influence the prevalence or the extent of silent myocardial ischaemia.

CONCLUSION

MPS did not identify greater ischaemia among IA compared with EW. This appears incongruent with almost 2-fold higher risk of CHD mortality observed in IA.

Epidemiology to public health intervention for preventing cardiovascular diseases: the role of translational research

Despite significant progress in medical research, cardiovascular diseases (CVDs) continue to be the largest contributors of morbidity and mortality both in developed and developing countries. The status of public health interventions related to CVDs prevention was reviewed to identify actions that are required to bridge the existing gap between the evidence and the policy. We used a framework comprising two steps - “bench to bedside” and from “bedside to community” to evaluate translational research. Available literature was reviewed to document the current status of CVD prevention and control at national level in India. Case studies of risk factor surveillance, tobacco control and blood pressure measurement were used to understand different aspects of translational research. National level initiatives in non-communicable diseases surveillance, prevention and control are a recent phenomena in India. The delay in translation of research to policy has occurred primarily at the second level, i.e., from ‘bedside to community’. The possible reasons for this were: inappropriate perception of the problem by policy makers and programme managers, lack of global public health guidelines and tools, and inadequate nationally relevant research related to operationalization and cost of public health interventions. Public health fraternity, both nationally and internationally, needs to establish institutional mechanisms to strengthen human resource capacity to initiate and monitor the process of translational research in India. Larger public interest demands that focus should shift to overcoming the barriers at community level translation. Only this will ensure that the extraordinary scientific advances of this century are rapidly translated for the benefit of more than one billion Indians.

High-molecular weight adiponectin is associated with coronary artery angiographic findings in Asian Indians

Asian Indians (AIs) have a higher prevalence and a more aggressive form of coronary artery disease (CAD), and it has been suggested that hypoadiponectinemia may have a role in this accelerated CAD. The present study was undertaken to determine the extent and severity of angiographic findings in 2 groups of CAD patients matched for age and sex, AIs (n = 29) vs whites (n = 30), and to elucidate the potential relationship between adiponectin (total and high-molecular weight [HMW] form) and the severity and extent of coronary angiographic findings in both groups. Angiographic findings were assessed using the modified Gensini index; and 2 scores, scores 1 and 2, were used to assess the severity and extent. Both Gensini index scores 1 and 2 were higher in the AI group compared with the white group (144.4 +/- 87.1 vs 93.5 +/- 56.3 and 127.2 +/- 86.5 vs 80.1 +/- 39.3, respectively; P < .05). Adiponectin levels were similar in both groups. Total adiponectin and HMW adiponectin were positively associated with Gensini index score 1 (r = 0.62, P = .004 and r = 0.64, P = .003) and score 2 (r = 0.51, P = .021 and r = 0.54, P = .013), respectively, in AI men, whereas there was no significant association in white men. Thus, AIs had more severe CAD compared with whites; and in AI men with CAD, total adiponectin and HMW adiponectin were associated with the severity of angiographic scores.

Atheroscerlotic heart disease in Bangladeshi immigrants: risk factors and angiographic findings

BACKGROUND

The prevalence of coronary artery disease (CAD) among Bangladeshis greatly exceeds that of Caucasians. Bangladeshis also suffer from premature onset, clinically aggressive and angiographically extensive disease. The role of conventional CAD risk factors (CCRFs) has been questioned. We therefore sought to determine if the CCRFs of Bangladeshis differed from non-Bangladeshis. We also sought to determine whether CAD was more extensive in Bangladeshis and if Bangladeshi ethnicity was independently predictive of extensive i.e., 3-vessel CAD at angiography.

METHODS

We reviewed the coronary angiograms and medical records of 75 Bangladeshis and 57 non-Bangladeshis presenting with myocardial infarction or angina pectoris.

RESULTS

Bangladeshis were younger (56.1 vs. 62.4 years, p=.001), had a lower body-mass index (25.2 vs. 27.2 kg/m(2), p=.017) and were less likely to be current or recent smokers (40% vs. 58%, p=.041) than non-Bangladeshis. There were no statistically significant differences in the proportion of subjects in the 2 groups with respect to diabetes mellitus, dyslipidemia, hypertension or family history of CAD. Bangladeshis had twice the rate of 3-vessel CAD of non-Bangladeshis (53% vs. 26%, p=.002). Bangladeshi ethnicity was independently associated with >3X the likelihood of having 3-vessel CAD at angiography (p=.011).

CONCLUSIONS

This study demonstrated that the CCRF burden of Bangladeshis with CAD is not excessive compared to that of non-Bangladeshis and is therefore unlikely to account for the excessive CAD risk found in this cohort. We also conclude that Bangladeshis have more angiographically extensive CAD than non-Bangladeshis and that Bangladeshi ethnicity is independently predictive of 3-vessel disease.

Nutrient Intake, Body Composition, Blood Cholesterol and Glucose Levels among Adult Asian Indians in the United States

Asian Indian (AI) immigrants have been suggested to be at increased risk for chronic disease. This study examined the metabolic risk factors for CVD among AI immigrants participating in a health fair in Southern Michigan, in the U.S. Participants included AI men (n = 44) and women (n = 57) who completed a demographic questionnaire, blood lipid (TC and HDL-C) and blood glucose (BG) test, resting BP check (SBP and DBP), body composition analysis and 24-h diet recall. For the entire group, the mean values were: BMI = 25.5, % body fat (BF) = 29.3; SBP = 129 mmHg; DBP = 76 mmHg; TC = 198 mg/dL; HDL-C = 48 mg/dL; BG = 111 mg/dL. Significant gender differences were observed: % BF (20% vs. 36%, P < 0.0001), lean body mass (122 vs. 48 lbs, P < 0.0001), HDL-C (42 vs. 52 mg/dL, P < 0.0025), TC/HDL-C (4.86 vs. 4.11, P < 0.03) and BG (122 vs. 105 mg/dL, P < 0.0001), for males and females, respectively. Dietary carbohydrate, protein and fat contributed 64, 14 and 25% of total energy intake. Among males, BMI was positively correlated with % BF (0.729, P < 0.01) and negatively correlated with HDL-C (-0.457, P < 0.05). Among females, BMI was positively correlated with % BF (0.801, P < 0.01), SBP (0.425, P < 0.05) and DBP (0.538, P < 0.01), and negatively correlated with % energy from saturated fat (-0.523, P < 0.01) and calcium intake (-0.445, P < 0.05). Despite having a dietary intake that meets the National Cholesterol Education Program, Adult Treatment Panel III recommendations, this group was at a higher risk for chronic disease, by virtue of increased BMI and % BF along with an altered metabolic profile (high BP and TC and low HDL-C).

Coronary artery diameter as a risk factor for acute coronary syndromes in Asian-Indians

Asian-Indians have high rates of coronary artery disease (CAD), which also occurs at an earlier age, with 50% of all heart attacks occurring in patients <55 years old and 25% in those <40 years old. Previous studies have cited structural factors in Asian-Indians, specifically smaller coronary arteries, as the cause of increased CAD in this population. We found that Asian-Indian patients have smaller coronary arteries, with a statistically significant difference in the mean diameter even after correction for body surface area.

Comparison of high-density and low-density lipoprotein cholesterol subclasses and sizes in Asian Indian women with Caucasian women from the Framingham Offspring Study

BACKGROUND

Asian Indian women have a higher rate of coronary artery disease (CAD) than do other ethnic groups, despite similar conventional risk factors and lipid profiles. Smaller high-density lipoprotein cholesterol (HDL-C) particle size is associated with reduced cardiac protection or even an increased risk of CAD. Exceptional longevity correlates better with larger HDL-C particle sizes.

HYPOTHESIS

Higher rates of CAD among Asian Indian women may partly be explained by the differenes in the prevalence of atherogenic HDL-C and low-density lipoprotein cholesterol (LDL-C) sizes and their subclass concentrations among Asian Indian women compared with Caucasian women.

METHODS

We measured HDL-C concentrations and sizes by nuclear magnetic resonance spectroscopy in 119 relatively healthy Asian Indian women and compared them with those of 1752 Caucasian women from the Framingham Offspring Study (FOS).

RESULTS

Asian Indian women were significantly younger (47.9 +/- 11.2 vs. 51.0 +/- 10.1 years, p = 0.0001), leaner (body mass index 24.0 +/- 4.7 vs. 26.0 +/- 5.6, p = < 0.0002), less likely to be postmenopausal (32 vs. 54%, p = < 0.0001), or smoke (< 1 vs. 20%, p = < 0.0001); nevertheless, prevalence of CAD was higher in Asian Indian women (4.2 vs. 1%, p = 0.0006). Asian Indian women had similar HDL-C (53 +/- 13 vs. 53 +/- 13 mg/dl, p = 0.99), smaller HDL-C particle size (8.9 +/- 0.35 vs. 9.4 +/- 0.44 nm, p = < 0.0001), higher total cholesterol (209 +/- 40 vs. 199 +/- 42 mg/dl, p = 0.01), and similar triglyceride (120 +/- 77 vs. 108 +/- 110 mg/d, p = 0.24) levels. Low-density lipoprotein cholesterol, particle concentrations and sizes, as well as prevalence of pattern B were similar.

CONCLUSIONS

Compared with the FOS, Asian Indian women have significantly smaller overall HDL particle size and similar levels of HDL-C, which may reflect impaired, reverse cholesterol transport. Total cholesterol was higher, whereas triglyceride and LDL-C levels were similar. This may partly explain the higher CAD rates in Asian Indian women. Further large scale, prospective, long-term studies are warranted.

Genes, diet and serum lipid concentrations: lessons from ethnically diverse populations and their relevance to coronary heart disease in Asia

PURPOSE OF REVIEW

The burden of coronary heart disease (CHD) in Asia has risen in tandem with socio-economic development and urbanization. Although all ethnic groups have been affected, some appear to be at particularly high risk. The basis of these ethnic differences remains poorly understood.

RECENT FINDINGS

Differing levels of risk factors for CHD have been observed between ethnic groups. Previous studies, however, may be confounded by a large ethnic variation in socio-economic status and place of residence. Few studies have taken dietary factors into account. Recent studies involving Chinese, Malays and Asian Indians living in Singapore suggest that neither dietary nor genetic factors, taken in isolation, sufficiently explain ethnic differences in serum lipid profiles. Several genetic variants in key candidate genes (apolipoprotein E, APOE, cholesteryl ester transfer protein, CETP and hepatic lipase, LIPC) have recently been found to modulate the association between dietary factors and serum lipid concentrations in these ethnic groups and in other populations.

SUMMARY

To fully evaluate the differences in CHD risk between ethnic groups, environmental exposures, including dietary factors need to be carefully evaluated, and gene-environment interactions that may give rise to these differences need to be taken into account. These are critical steps in the development of targeted strategies to contain the epidemic of coronary heart disease in Asia. An understanding of the basis of these differences may also provide insights into the pathogenesis of disease that one cannot get through the examination of more homogenous populations.